Power-Assisted Liposuction and Lipofilling: Techniques and Experience in Large-Volume Fat Grafting.

BACKGROUND: Power-assisted liposuction and lipofilling (PALL) is a simple and reproducible surgical technique for large volume fat grafting. OBJECTIVES: The authors share their 7-year experience with their large-volume fat transfer technique, PALL. METHODS: A total of 417 patients who underwent PALL-related surgeries involving the breast and buttock were evaluated in a retrospective study. Liposculpting and fat harvesting were performed with power-assisted liposuction. Fat was transferred with simultaneous power-assisted vibration and tunnelization to provoke expansion of the recipient site. Following lipofilling, additional external vibration of the recipient site was performed to enhance diffusion of the injected fat. RESULTS: Liposuction volumes up to 5000 mL were recorded, and injection volumes ranged from 300 to 900 mL per side for each session. Operating times ranged from 45 to 120 minutes. Patients were followed-up for 1 to 4 years. No major complications were recorded. CONCLUSIONS: PALL is an efficient, safe, and reproducible procedure with myriad applications in aesthetic and reconstructive surgery.Level of Evidence: 4.

The V-Plasty: A Novel Microsurgical Technique for Anastomosis of Vessels with Marked Size Discrepancy.

BACKGROUND: The art of reconstructive microsurgery is still progressing after Carrel's original description of "vascular repair" in 1902. Reports of the successful repair of vessels smaller than 1 mm in diameter are currently commonplace. However, the technique of microvascular anastomosis to connect vessels with large diameter discrepancy, greater than 1 mm, has not yet been perfected. This article reports a novel option to anastomose two vessels of different sizes by adapting the diameters of the two stumps and creating a gentle slope that dramatically reduces turbulences in the blood stream. METHODS: The "V-plasty" consists in designing a v-shaped flap on the wall of the large vessel and a longitudinal incision on the small one. The V-flap is then introduced into the V-defect of the small vessel, creating a smooth transition of the diameters between the two vessels. Mathematical calculation of the dimensions of the V-flap was conducted with different ratios' discrepancies of the two vessels ranging from 1.5 to 4. Clinically, 14 microvascular V-plasty were performed in 8 patients. RESULTS: The theoretical simulation and our clinical experience of 14 cases allowed us to propose the different dimensions (length and width) of the V-plasty according to the ratio of vessels discrepancies. CONCLUSION: The V-plasty microanastomosis is an alternative method to attach vessels with size discrepancy. It simply equalizes the donor and recipient vessels' diameters. Its main advantage is to maintain a linear axis between the two vessels whatever the discrepancy ratio is.

Power-Assisted Liposuction Mammaplasty (PALM): A New Technique for Breast Reduction.

BACKGROUND: Resection and reshaping of the parenchyma are common procedures to produce a natural breast shape in reduction mammaplasty and mastopexy. The challenges of these practices include maintaining sensitivity of the nipple-areola complex (NAC), achieving upper-pole fullness, and preserving an adequate blood supply for patients with massive breast ptosis. OBJECTIVES: The authors describe their experience with power-assisted liposuction mammaplasty (PALM), a novel technique for breast reduction. METHODS: One hundred fifty consecutive women (300 breasts) who underwent PALM were evaluated in a prospective study. Minimizing skin undermining and glandular resection ensured maximal blood supply to the breast. A lateral pedicle was created to preserve NAC sensitivity. The transposed gland was contained within a large pocket made in the upper-inner quadrant. Glandular suspension sutures from the dermis to the chest wall stabilized the breast and recreated the inframammary fold. RESULTS: The mean distance from the nipple to the sternal notch was 36 cm, the mean NAC elevation was 16 cm, the mean lipoaspirate volume per breast was 650 cc, and the mean glandular resection mass per breast was 240 g. Complications included wound infection (6 of 300 breasts, 2%), wound dehiscence (3 breasts, 1%), and seroma (9 breasts, 3%). Partial areolar necrosis occurred in 2 of 150 patients (1.3%), and 9 patients (6%) underwent revisional surgery. CONCLUSIONS: PALM is a safe and reliable option for breast reduction and is indicated for patients with massive breast ptosis. LEVEL OF EVIDENCE 4: Therapeutic.

Brachioplasty by Power-Assisted Liposuction and Fat Transfer: A Novel Approach That Obviates Skin Excision.

BACKGROUND: Current brachioplasty techniques include excisional surgery alone or in combination with liposuction. These techniques are associated with poor outcomes, such as residual contour deformities and unfavorable scarring. OBJECTIVES: The authors proposed a new classification system and treatment algorithm for brachial ptosis and described their experience with power-assisted liposuction and lipofilling to treat brachial ptosis without excisional surgery. METHODS: Ninety-five patients with grades 1, 2, or 3 brachial ptosis who underwent brachioplasty were evaluated in a prospective study. Power-assisted liposuction was applied to the posterior arm and para-axillary region, and power-assisted lipofilling was applied to the so-called "bicipital triangle" of the medial arm. RESULTS: The patients' mean age was 39 years, mean body mass index was 28 kg/m(2), mean lipoaspirate volume was 240 mL per arm, and mean fat-injection volume was 110 mL per side. The mean operating time was 50 minutes, and the average follow-up period was 24 months. Hematoma developed in 2 patients who underwent brachioplasty in combination with another body contouring procedure (1 abdominal hematoma and 1 thigh hematoma; 2.1% complication rate). No other complications were recorded. CONCLUSIONS: Brachioplasty by means of power-assisted liposuction and lipofilling is a safe and reliable option that obviates excisional surgery in patients with mild to moderate brachial ptosis. LEVEL OF EVIDENCE: 4 Therapeutic.

Refractory sickle cell leg ulcer: is heparan sulphate a new hope?

Patients with sickle cell disease are known to have recurrent lower extremity ulcers that have a high pain score and are resistant to conventional means of wound therapy. This study reports the successful use of synthetic heparan sulphate (Cacipliq20(®) , OTR3, Paris, France) in the treatment of a sickle cell ulcer that had failed to respond to several other means of treatment. Therapeutic success was assessed by complete wound coverage and vast improvement in pain score. This is the first study to report use of heparan sulphate in sickle cell ulcers.

Functional and Therapeutic Indications of Liposuction: Personal Experience and Review of the Literature.

Liposuction is the most common cosmetic surgical procedure worldwide. It has evolved from being designed primarily for body contouring to becoming essential adjunct to various other aesthetic procedures, greatly enhancing their outcome. Despite its hard clear differentiation between an aesthetic and therapeutic indication for some pathologic conditions, liposuction has been increasingly applied to a gamut of disorders as a therapeutic tool or to improve function. In fact, liposuction has ceased to define a specific procedure and became synonymous to a surgical technique or tool same as the surgical knife, laser, electrocautery, suture material, or even wound-dressing products. At present, there seems to be an enormous potential for the application of the basic liposuction technique in ablative and reconstructive surgery outside the realm of purely aesthetic procedures. The present review contemplates the various nonaesthetic applications of liposuction, displaying the enormous potentials of what should be considered a basic surgical technique rather than a specific aesthetic procedure. Implications of this new definition of liposuction should induce third-party public payers and insurance companies to reconsider their remuneration and reimbursement policies.

Overcoming limitations of short scar minimal access cranial suspension facelift for enhanced rejuvenation.

The minimal access cranial suspension lift, a short-scar facelift, has been described to correct sagging and laxity of the lower and middle third of the face. It does not, however, fully address the neck or the lateral periorbital area frequently needing rejuvenation in most patients. Another shortcoming of the minimal access cranial suspension lift technique is visible scarring anterior to the temporal hairline that usually occurs despite the suggested surgical maneuvers consisting in zigzag beveled incisions. We describe modifications of the standard subcutaneous musculoaponeurotic system lift technique, increasing its indications for full-face and neck rejuvenation (excluding the forehead) and improving final aesthetic outcome.

Immediate Large-Volume Grafting of Autologous Fat to the Breast Following Implant Removal.

BACKGROUND: To optimize autologous breast augmentation, a simple and reproducible surgical approach that maximizes the volume of fat transferred to the breast while minimizing the number of sessions and the operating time is needed. OBJECTIVES: The authors describe a novel approach for large-volume fat grafting to the expanded skin and subcutaneous tissue of the breast immediately after explantation, exchanging the volume provided by the implants with transplanted fat in a single session. METHODS: Eighty patients (160 breasts) undergoing explantation and autologous fat transfer were evaluated in a prospective study. Fat was harvested with the lipomatic power-assisted liposuction machine (Lipomatic Eva SP, Euromi SA, Verviers, Belgium) and was injected with simultaneous vibration and tunnelization of the recipient site by means of the same machine with suction disabled. Changes in breast volume were measured in terms of bra cup size, and patients were monitored by mammography and ultrasonography. Patient satisfaction was assessed with a questionnaire administered 6 months postoperatively. RESULTS: Injected fat volumes ranged from 300 to 600 mL per breast. Operating times ranged from 45 to 90 minutes. For all patients, one injection session was sufficient to replace the volume of the previous implant. Patients were monitored for an average of 2 years, and complications included cyst formation in 9 of 160 breasts (5.6%) and infection in 2 breasts (1.25%). CONCLUSIONS: Power-assisted transfer of autologous fat to the breast improves the ability of the recipient site to receive the graft and allows for explantation and fat transplantation in a single session. This approach is suitable for patients who desire a natural-appearing breast that is similar in volume to their previous implant.

Power-assisted gluteal augmentation: a new technique for sculpting, harvesting, and transferring fat.

BACKGROUND: A simple and reproducible surgical technique for gluteal shaping and augmentation with autologous fat is needed. OBJECTIVES: The authors describe a novel approach to large-volume gluteal augmentation that combines power-assisted liposculpting and fat harvesting of the zones around the buttock with autologous fat transfer. METHODS: One hundred ten patients who underwent gluteal augmentation were evaluated in a prospective study. Liposculpting and fat harvesting were performed with power-assisted liposuction. Fat then was transferred to the gluteal region with simultaneous power-assisted vibration and tunnelization. A questionnaire to assess patient satisfaction was administered at 6 months postoperatively. RESULTS: The mean body mass index of the patients was 30 kg/m(2) (range, 26-36 kg/m(2)). Liposuction volumes ranged from 1400 to 5000 mL, and injection volumes ranged from 300 to 900 mL per side for each session. Operating times ranged from 60 to 120 minutes. Patients were monitored for an average of 20 months (range 12-48 months). Complications included a burning sensation in 5 of 110 patients (4.5%), persistent swelling in the lower back in 3 patients (2.7%), and a mild infection in 1 patient (0.9%). CONCLUSIONS: Power-assisted gluteal augmentation with autologous fat is an efficient, safe, and reproducible procedure that produces an aesthetically pleasing gluteal projection and contour. LEVEL OF EVIDENCE: 4 Therapeutic.

Preoperative assessment tool for the planning of inframammary incision and implant profile in breast augmentation.

When using the inframammary access incision for breast augmentation, careful planning is critical to allow the surgeon to set the inframammary fold (IMF) at the most optimal position, minimize scar visibility, and mitigate the main disadvantage of this approach. Current popular evaluation systems for breast augmentation include the High Five and Randquist systems and they base their calculations on inconsistent variables like skin stretch measurements. We propose a simple method that is not dependent on skin stretch measurements to properly determine implant size, profile, and position of the inframammary fold. Excluding digital scans and computer-based systems that are not universally available, the proposed simplified assessment tool was compared to the two most popular manual measuring tools (High Five and Randquist). Twenty-five female volunteers were included in the study. The projected IMF positions over the midsternal line for each measuring tool were recorded on each patient and the sternal notch (SN) to projected IMF distance SN-IMF1 (simplified evaluation system), SN-IMF2 (High Five System), and SN-IMF3 (Randquist system) were compared. The anticipated new IMF position is determined based on the vertical implant dimension and not on breast base width. For most subjects, the differences between the three evaluation systems were minimal. The proposed breast measurement tool constitutes a new, much simpler, and practical method that proved to be successful in our hands.

Reverse tissue expansion by liposuction deflation for revision of post-surgical thigh scars.

Scars hypertrophy and widen when stretching mechanical forces are applied to resilient newly formed collagen before it reaches final maturity marring the final result of many surgical procedures and resulting in a clinical problem for many patients. Scar revision by surgical excision remains the traditional treatment for hypertrophic or widespread scars. It relies upon recruitment of local tissues for closure of the ensuing defect. Providing tension-free skin closure is the best option to avoid recurrence. Although tissue expansion procedure is a valuable and reliable technique for scar revision, it has its own disadvantages and potential complications. We describe an alternative method for scar revision that may be applicable in certain situations. Instead of expanding the soft tissues to make available additional skin, deflation by liposuction may be affected to relax the skin envelope thus indirectly providing additional skin for scar revision. We call this method 'reverse tissue expansion'.

A New Suturing Method for Optimal Wound Healing: Technique and Experience.

BACKGROUND: Wound closure utilizing barbed sutures has been associated with healing problems, such as thread extrusion, infection, and the increase of an inflammatory response around the scar. OBJECTIVES: In our study, the senior author described a novel technique of skin incision and wound closure based on de-epithelization and bi-layer tension-free closure that minimizes complications. METHODS: In this retrospective study, the authors reviewed the evolution of wound healing for the novel technique developed by the senior author by analyzing clinical reports of 817 patients who underwent surgery for abdominoplasty or breast reduction utilizing power-assisted liposuction mammaplasty with the new incision and closure technique. In addition, three separate plastic surgeons reviewed the wound characteristics and overall appearance by analyzing photographs that were taken over the course of 12 months to document the healing process. RESULTS: The overall complication rate was 14.1%, with 0.4% hematoma, 1.25% infection, 0.8% seroma, 1.5% necrosis, 3.75% erythema, 3.3% delayed wound healing, and 3.1% suture extrusion. The authors reported the rate of step-off border (9%), contour irregularities (6.5%), margin separation (1.25%), edge inversion (3.2%), excessive distortion (0.9%), and bad overall appearance (6.4%) of the cases. CONCLUSIONS: This new technique in wound incision and closure based on de-epithelization and bilayer tension-free closure reduces the complications associated with barbed sutures.

Corrigendum to: A New Suturing Method for Optimal Wound Healing: Technique and Experience.

[This corrects the article DOI: 10.1093/asjof/ojaa008.].

Vertical and horizontal coordinates of the nipple-areola complex position in males.

After massive weight loss, male breasts in particular are one of the most disturbing body regions and can be a difficult area to treat often requiring nipple-areola repositioning. The need for bilateral repositioning of the nipple-areola complex is also increasing in other surgical fields such as in female-to-male transsexual patients with large breasts and in patients with severe forms of gynecomastia. Proper configuration and localization of the nipple-areola complex requires both meticulous planning and a thorough understanding of the male anatomy and is essential in determining final aesthetic outcome. Currently available guidelines create areolas that are too large, place the nipple-areola complex too high and too far medially, and/or require complex abstract mathematical calculations. Relying on the recently appreciated aesthetic value of the golden number Phi (phi) we propose an easy and reliable method to determine the horizontal and vertical coordinates of the male nipples. With only 2 easily measurable distances, umbilicus-anterior axillary fold apex and umbilicus-suprasternal notch, the internipple distance and the position of the horizontal nipple plane relative to the suprasternal notch can be calculated. The internipple distance can be determined with 95% accuracy and the distance from the suprasternal notch can be determined in 80% of cases within a range of 3.33 +/- 1.25 cm.

Nonsurgical nonablative treatment of aging skin: radiofrequency technologies between aggressive marketing and evidence-based efficacy.

The gold standard treatment for the many aesthetic aspects of aging has for many years been surgery in its many forms. However, with increasing patient demand for cosmetic rejuvenation and with the strong desire and drive by patients to attain aesthetic enhancement with minimal risk and rapid recovery, there has been a strong surge inspiring the field of nonsurgical skin rejuvenation. Traditionally, most of the nonsurgical methods have centered around those that destroy the epidermis and cause a dermal wound, with resultant dermal collagen remodeling and secondary skin tightening and rhytid improvement. Currently, there is growing interest in a wide range of nonablative interventions that, predictably, are claimed to rejuvenate skin and subcutaneous tissue "safely and effectively." Although several nonablative systems have been cleared by the U.S. Food and Drug Administration (FDA) for the purpose of skin rejuvenation and despite significant reported improvement in the appearance of signs and symptoms of photoaging by relatively noninvasive means, the clinical results have been generally less than impressive, with most subjects showing only mild improvement. The current review aims at summarizing the various nonablative methods currently in use for skin rejuvenation and to evaluate the evidence-based efficacy of a particular nonablative radiofrequency (NARF) method: monopolar radiofrequency.

Wound cleansing, topical antiseptics and wound healing.

Quality of care is a critical requirement for wound healing and 'good' care of wounds has been synonymous with topical prevention and management of microbial contamination. Topical antiseptics are antimicrobial agents that kill, inhibit or reduce the number of microorganisms and are thought to be essential for wounds infection control. However, they have long and commonly been used on wounds to prevent or treat infection, the merits of antiseptic fluid irrigation have received little scientific study. Unlike antibiotics that act selectively on a specific target, antiseptics have multiple targets and a broader spectrum of activity, which include bacteria, fungi, viruses, protozoa and even prions. Although certain skin and wound cleansers are designed as topical solutions with varying degrees of antimicrobial activity, concerns have been raised. Wound cleansers may affect normal human cells and may be antimitotic adversely affecting normal tissue repair. Repeated and excessive treatment of wounds with antiseptics without proper indications may have negative outcomes or promote a microenvironment similar to those found in chronic wounds. However, when applied at the proper times and concentrations, some classes of antiseptics may provide a tool for the clinician to drive the wound bed in desired directions. The present review summarises the various antiseptics in use and their negative impact on the wound healing mechanisms. It is clear that the role of antiseptics on wounds and their role in wound care management need to be reconsidered.

Modulation of wound contracture alpha-smooth muscle actin and multispecific vitronectin receptor integrin alphavbeta3 in the rabbit's experimental model.

The myofibroblast, a major component of granulation tissue, is a key cell during wound healing, tissue repair and connective tissue remodelling. Persistence of myofibroblasts within a fibrotic lesion leads to excessive scarring impairing function and aesthetics. Various wound-healing cytokines can be modulated by topical application of active agents to promote optimal wound healing and improve scar quality. Thus, the myofibroblast may represent an important target for wound-healing modulation to improve the evolution of conditions such as hypertrophic scars. The purpose of this work is to study the modulation of myofibroblasts and integrin alphavbeta3 in a full thickness wound performed on rabbits treated with different topical agents using: (1) saline, (2) Tegaderm occlusive dressing (3) silver sulfadiazine and (4) moist exposed burn ointment (MEBO). The reepithelialisation was 4 days faster in the MEBO group compared with the other therapies with less oedema formation, delayed contraction, less inflammatory cells and the lowest transepidermal water loss (TEWL) resulting in a soft scar. Although alpha-smooth muscle actin (alpha-SMA) was the highest around day 12 in the MEBO group, wound contraction and myofibroblast's activity were the least for the same period probably because of a downregulation of the integrin alphavbeta3. It seems that the effect of MEBO could be more pronounced on force transmission rather then on force generation. Greater insight into the pathology of scars may translate into non surgical treatments in the future and further work in myofibroblast biology will eventually result in efficient pharmacological tools, improving the evolution of healing and scar formation.

Cosmetic mesotherapy: between scientific evidence, science fiction, and lucrative business.

Mesotherapy, originally conceived in Europe, is a minimally invasive technique that consists of the intra- or subcutaneous injection of variable mixtures of natural plant extracts, homeopathic agents, pharmaceuticals, vitamins, and other bioactive substances in microscopic quantities through dermal multipunctures. Its application in cosmetic medicine and surgery is gaining in popularity and acceptance and is rapidly growing in profile at an alarming rate. Despite their attraction as purported rejuvenating and ''fat-dissolving'' injections, the safety and efficacy of these novel cosmetic treatments remain ambiguous, making mesotherapy vulnerable to criticism by the generally more skeptical medical community. The technique is shrouded in mystery and the controversy surrounding it pertains to its efficacy and potential adverse effects that are subject of much concern. As with any new technology, it is important to assess the benefits, safety, experience, and standardization of mesotherapy. More studies are necessary before it can be advocated as a safe and effective treatment for body contouring and facial rejuvenation. Although the claims made about mesotherapy may be hard to believe at face value, we must be cautious about rejecting new ideas. Just as absence of proof is not proof of absence, lack of scientific validation is not proof that it does not work.